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Out of Network Coverage

You must receive your care from a network provider

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. Here are three exceptions:

  • Medical emergency care or urgently needed services that you get from an out-of-network provider. (For more information about this and examples of what emergency or urgently needed services means, please see below.)
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Authorization must be obtained from the plan before seeking care. When this happens, we will cover these services as if you got the care from a network provider.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside University of Maryland Health Advantage’s service area.

Medical emergencies

A “medical emergency” is when you believe that you have medical symptoms that require immediate medical attention to prevent death, loss of a limb, or loss of function of a limb.  The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

Urgently needed services

“Urgently needed services” are non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition that you have.

For Medical and Hospital Claims:

When you go to a network provider or facility they will automatically submit their claims to us for payment.  However, if you are outside the service area and obtain emergency services, urgently needed care, or renal dialysis, show your University of Maryland Health Advantage ID Card and ask that the claims be sent directly to us.  If the provider and/or facility will not bill us directly, you will need to submit the claim to us at the address below:

University of Maryland Health Advantage
c/o Claims Department
P.O. Box 1955
Bowie, MD  20717-1955

For Prescription Drug Claims

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our mail order pharmacy service. University of Maryland Health Advantage has a nationwide pharmacy network so even if you are outside the service area, you will probably be able to find a network pharmacy in the area in which you are traveling.

If you are traveling within the US and become ill, or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules. Prior to filling your prescription at an out-of-network pharmacy, call Member Services to find out if there is a network pharmacy in the area where you are traveling.  We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

If you have to purchase a covered drug at a non-network pharmacy while outside of the service area due to an emergency or urgently needed care, please submit your request for reimbursement to us at the address provided below:

University of Maryland Health Advantage
c/o CVS Caremark
P.O. Box 52066 Phoenix, AZ 85072-2066

For Medical and Hospital Claims:

When you go to a network provider or facility, they will automatically submit their claims to us for payment.  However, if you are outside the service area and obtain emergency services, urgently needed care, or renal dialysis, show your University of Maryland Health Advantage ID Card and ask that the claims be sent directly to us.  If the provider and/or facility will not bill us directly, you will need to submit the claim to us at the address below:

University of Maryland Health Advantage
Attn: Claims Department
P.O. Box 1955
Bowie, MD  20717-1955

For Prescription Drug Claims

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, submit your claim and your receipt to the below address.

University of Maryland Health Advantage
c/o CVS Caremark
P.O. Box 52066
Phoenix, AZ 85072-2066

You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible (and it is not reasonable to wait to obtain care from your network provider when the network becomes available), we will cover urgently needed services that you get from an out-of-network provider.

When you are outside the service area and cannot get care from a network provider, University of Maryland Health Advantage will cover urgently needed services that you get from any provider.

We will cover prescriptions filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost, if applicable, by submitting a paper claim to:

University of Maryland Health Advantage, c/o CVS Caremark 
P.O. Box 52066
Phoenix, AZ 85072-2066.